HomeMy WebLinkAbout0036 MAPLE WAY - Health (2) 36 Maple Way
Hyannis
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
t
r� 36 Maple Way °'
M gaM
Property Address
Whitlock/Clark
Owner Owner's Name
information is -i
required for West Hyannisport ✓ MA 8-5-17 r
every page. Cityrrown State Zip Code Date of Inspection _
it s
Inspection results must be submitted on this form. Inspection forms may not be altered in any
way. Please see completeness checklist at the end of the form.
Important: A. General Information
When filling out
forms on the
computer,use 1. Inspector:
only the tab key
to move your DOUGLAS A BROWN
cursor-do not Name of Inspector
use the return
key. D.A.BROWN INC
Company Name
P.O. BOX 145
Company Address
CENTERVILLE MA 02632
Cityrrown State Zip Code
508-420-4534 S14297
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5(310 CMR 15.000).The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
�-�--- 8-5-17
I nsoe—ctors,SA.nature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is p
required for y West H annis ort MA 8-5-17
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
® 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
At time of inspection system met all minimum passing requirements.This report can not predict the
future performance under the same or increased usage.
B) System Conditionally Passes:
❑ One or more system components as described in the"Conditional Pass"section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years.old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
I
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Maple Way,
Property Address
Whitlock/Clark
Owner Owners Name
information is
required for West Hyannisport MA 8-5-17
every page. CitylTown State Zip Code Date of Inspection
B. Certification (cont.)
❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if
pumps/alarms are repaired.
B) System Conditionally Passes(cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
a Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
, 36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is required for West HY P annis ort MA 8-5-17
every page. Citylrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health(and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well**.
Method used to determine distance:
**This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal
coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal
P 9 9 q
to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must
be attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes. No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than %day flow
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Maple Way
Property Address
Whitlock/Clark
Owner owner's Name
information is ort MA 8-5-17 West H annis
required for Y P
every page. Cityrrown State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well.
❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 15,000 gpd.
For large systems, you must indicate either"yes"or"no"to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA)or a mapped Zone II of a public water supply well
If you have answered"yes"to any question in Section E the system is considered a significant threat,
or answered"yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
I _�
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is required for West Hy p annis ort MA 8-5-17
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes"or"no"as to each of the following:
Yes No
❑ ® Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined?(If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System(SAS)on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information _
Residential Flow Conditions:
Number of bedrooms(design): 3 Number of bedrooms(actual): 3
DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 330
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is West Hyannis port MA 8-5-17
required for P
every page. Citylrown State Zip Code Date of Inspection
D. System Information
Description:
According to as-built card system consists of a 1500 fiberglass tank, d box, and s.a.s consisting of
infiltrators and stone.
Number of current residents: varying
Does residence have a garbage grinder? ❑ Yes ® No
Is laundryon a separate sews e system? Include laundry system inspection P 9 ; Y ( rY Y P
information in this report.) El Yes ® No
Laundry system inspected? ❑ Yes ® No
Seasonal use? ❑ Yes ❑ No
Water meter readings, if available(last 2 years usage(gpd)):
Detail:
2015-----337 2016----296 gpd System not designed for use with garbage disposal.
Sump pump? ❑ Yes ❑ No
Last date of occupancy: 2017
Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow(based on 310 CMR 15.203):
Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
„ s 36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is required for West Hy p annis ort MA 8-5-17
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: 2017
Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped:
gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner)and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
M 5+ay`'y 36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is required for West HY P annis ort MA 8-5-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known)and source of information:
11-15-05 per as-built
Were sewage odors detected when arriving at the site? ❑ Yes ® No
Building Sewer(locate on site plan):
Depth below grade: feet
Material of construction:
❑ cast iron ❑40 PVC ❑ other(explain):
Distance from private water supply well or suction line: feet
Comments(on condition of joints, venting, evidence of leakage, etc.):
Septic Tank(locate on site plan):
Depth below grade: 2.5
feet
Material of construction:
❑concrete ❑ metal ®fiberglass ❑ polyethylene ❑ other(explain)
If tank is metal, list age:
years
Is age confirmed by a Certificate of Compliance?(attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500
Sludge depth: light to moderate
t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is
required for West Hyannisport MA 8-5-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank(cont.)
Distance from top of sludge to bottom of outlet tee or baffle
Scum thickness light
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
How were dimensions determined? woodem pole
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
If tank has not been pumped in the past 2-3 yrs I recommend pumping now and at time of transfer for
maintenance and every 3 yrs there after.
1
Grease Trap(locate on site plan):
Depth below grade: feet
Material of construction:
❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
9 p Y rY
36 Maple Way
Property Address
Whitlock/Clark
Owner Owners Name
information is p
required for y West H annis ort MA 8-5-17
every page. Citylrown State Zip Code Date of Inspection
D. System Information (cont.)
Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments(condition of alarm and float switches, etc.):
"Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is required for West Hy p annis ort MA 8-5-17
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box(if present must be opened) (locate on site plan):
..
Depth of liquid level above outlet invert o
Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
box was opened and found to be in working order with no signs of failure or solid carry over.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No"
Alarms in working order: ❑ Yes ❑ No"
Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.):
*If pumps or alarms are not in working order, system is a conditional pass.
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
could not find observation port.
t5ins•3/13 Title 5 Official Inspection Forth:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is required for West Hy p annis ort MA 8-5-17
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ leaching pits number:
® leaching chambers number: infiltrators
❑ leaching galleries number:
❑ leaching trenches number, length:
❑ . leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Observation port was not able to'be located. we did probe into soils in area of s.a.s and did not find
anything but clean dry soils. Exact level of ponding could not be determined.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 13 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is
required for West Hyannisport MA 8-5-17
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy(locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•3113 Title 5 official Inspection Fonn:Subsurface Sewage Disposal System•Page 14 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is p
required for y West H annis ort MA 8-5-17
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to
at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate
where public water supply enters the building. Check one of the boxes below:
❑ hand-sketch in the area below
® drawing attached separately
t5ins•3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
M 36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is p
required for y West H annis ort MA 8-5-17
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water.
® Check cellar
® Shallow wells
Estimated depth to high ground water: greater than 5
feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 8-2017
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
❑ Checked with local Board of Health-explain:
❑ Checked with local excavators, installers-(attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high ground water elevation:
design plan
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
I
• f . •-} � is • ,
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form-Not for Voluntary Assessments
36 Maple Way
Property Address
Whitlock/Clark
Owner Owner's Name
information is ort MA 8-5-17 West H annis
required for Y P
every page. City[Town State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D(System Failure Criteria Applicable to All Systems)completed
® System Information—Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17
Assessing As-Built Cards Page 2 of 2 .
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Separation Distance Between the:
Maximum Adjusted Groundwater Table to the Bottom of Leaching Facility Feet
Private Water Supply Well and Leaching Facility (If any wells exist
on site or within 200 feet of leaching facility) Feet
Edge of Wetland and Leaching Facility(If any wetlands exist
within 300 feet of leaching facility) Feet
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Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
^M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for WY P H annis ort Ma. 02672 5/13/2010
— _
every page. City/Town State Zip Code Date of Inspection
Inspection results must be submitted on this form. Inspection forms may not be altered in;;any;
way. Please see completeness checklist at the end of the form.
Important:When filling out A. General Information
forms on the
computer,use 1. Inspector:
only the tab key
to move your Robert Paolini
cursor-do not Name of Inspector
use the return
key. Capewide Enterprises,LLC.
Company Name
� P.O.Box 763
Company Address
Centerville Ma. 02632
rM City/Town State Zip Code
(508)428-4028 S14454
Telephone Number License Number
B. Certification
I certify that I have personally inspected the sewage disposal system at this address and that the
information reported below is true, accurate and complete as of the time of the inspection. The inspection
was performed based on my training and experience in the proper function and maintenance of on site
sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of
Title 5 (310 CMR 15.000). The system:
® Passes ❑ Conditionally Passes ❑ Fails
❑ Needs Further Evaluation by the Local Approving Authority
5/13/2010
Inspector's Signature Date
The system inspector shall submit a copy of this inspection report to the Approving Authority(Board
of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or
has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the
report to the appropriate regional office of the DEP. The original should be sent to the system owner
and copies sent to the buyer, if applicable, and the approving authority.
****This report only describes conditions at the time of inspection and under the conditions of use
at that time.This inspection does not address how the system will perform in the future under
the same or different conditions of use.
5
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage D os,at System•Pa 1 of 17
i
~ Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for Y P W H annis ort Ma. 02672 5/13/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Inspection Summary: Check A,B,C,D or E/always complete all of Section D
A) System Passes:
❑ 1 have not found any information which indicates that any of the failure criteria described
in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are
indicated below.
Comments:
The septic system is in proper working order at the present time.
B) System Conditionally Passes:
❑ One or more system components as described in the "Conditional Pass" section need to be
replaced or repaired. The system, upon completion of the replacement or repair, as approved by
the Board of Health, will pass.
Check the box for"yes", "no" or"not determined" (Y, N, ND) for the following statements. If"not
determined," please explain.
The septic tank is metal and over 20 years old* or the septic tank (whether metal or not) is
structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System
will pass inspection if the existing tank is replaced with a complying septic tank as approved by the
Board of Health.
*A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of
Compliance indicating that the tank is less than 20 years old is available.
❑ Y ❑ N ❑ ND (Explain below):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
wM 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is W H required for annis ort Ma. 02672 5/13/2010
y p
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
B) System Conditionally Passes (cont.):
❑ Observation of sewage backup or break out or high static water level in the distribution box due
to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will
pass inspection if(with approval of Board of Health):
❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The
system will pass inspection if(with approval of the Board of Health):
El broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below):
❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below):
C) Further Evaluation is Required by the Board of Health:
❑ Conditions exist which require further evaluation by the Board of Health in order to determine if
the system is failing to protect public health, safety or the environment.
1. System will pass unless Board of Health determines in accordance with 310 CMR
15.303(1)(b)that the system is not functioning in a manner which will protect public health,
safety and the environment:
❑ Cesspool or privy is within 50 feet of a surface water
❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�^M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for y p W H annis ort Ma. 02672 5/13/2010
every page. Cityfrown State Zip Code Date of Inspection
B. Certification (cont.)
2. System will fail unless the Board of Health (and Public Water Supplier, if any)
determines that the system is functioning in a manner that protects the public health,
safety and environment:
❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within
100 feet of a surface water supply or tributary to a surface water supply.
❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water
supply.
❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water
supply well.
❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or
more from a private water supply well".
Method used to determine distance:
** This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform
bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or
less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be
attached to this form.
3. Other:
D) System Failure Criteria Applicable to All Systems:
You must indicate"Yes" or"No"to each of the following for all inspections:
Yes No
❑ ® Backup of sewage into facility or system component due to overloaded or
clogged SAS or cesspool
❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters
due to an overloaded or clogged SAS or cesspool
❑ ® . Static liquid level in the distribution box above outlet invert due to an overloaded
or clogged SAS or cesspool
❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less
than '/day flow
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 4 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for Y p W H annis ort Ma. 02672 5/13/2010
every page. City/Town State Zip Code Date of Inspection
B. Certification (cont.)
Yes No
❑ ® Required pumping more than 4 times in the last year NOT due to clogged or
obstructed pipe(s). Number of times pumped:
❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation.
❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or
tributary to a surface water supply.
❑ ® Any portion of a cesspool or privy is within.a Zone 1 of a public well.
Any portion of a cesspool or privy is within 50 feet of a private water supply
El ® Pp Y
well.
❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet
from a private water supply well with no acceptable water quality analysis. [This
system passes if the well water analysis, performed at a DEP certified
laboratory,for fecal coliform bacteria indicates absent and the presence
of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,
provided that no other failure criteria are triggered.A copy of the analysis
and chain of custody must be attached to this form.]
❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd-
10,000gpd.
❑ ® The system fails. I have determined that one or more of the above failure
criteria exist as described in 310 CMR 15.303, therefore the system fails. The
system owner should contact the Board of Health to determine what will be
necessary to correct the failure.
E) Large Systems: To be considered a large system the system must serve a facility with a
design flow of 10,000 gpd to 16,000 gpd.
For large systems, you must indicate either"yes" or"no" to each of the following, in addition to the
questions in Section D.
Yes No
❑ ❑ the system is within 400 feet of a surface drinking water supply
❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply
❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection
Area—IWPA) or a mapped Zone II of a public water supply well
If you have answered "yes"to any question in Section E the system is considered a significant threat,
or answered "yes" in Section D above the large system has failed. The owner or operator of any large
system considered a significant threat under Section E or failed under Section D shall upgrade the
system in accordance with 310 CMR 15.304. The system owner should contact the appropriate
regional office of the Department.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form -Not for Voluntary Assessments
°M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for y p W H annis ort Ma. 02672 5/13/2010
every page. City/Town State Zip Code Date of Inspection
C. Checklist
Check if the following have been done. You must indicate"yes" or"no"as to each of the following:
Yes No
® ❑ Pumping information was provided by the owner, occupant, or Board of Health
❑ ® Were any of the system components pumped out in the previous two weeks?
® ❑ Has the system received normal flows in the previous two week period?
❑ ® Have large volumes of water been introduced to the system recently or as part of
this inspection?
® ❑ Were as built plans of the system obtained and examined? (If they were not
available note as N/A)
® ❑ Was the facility or dwelling inspected for signs of sewage back up?
® ❑ Was the site inspected for signs of break out?
® ❑ Were all system components, excluding the SAS, located on site?
® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank
inspected for the condition of the baffles or tees, material of construction,
dimensions, depth of liquid, depth of sludge and depth of scum?
® ❑ Was the facility owner(and occupants if different from owner) provided with
information on the proper maintenance of subsurface sewage disposal systems?
The size and location of the Soil Absorption System (SAS) on the site has
been determined based on:
® ❑ Existing information. For example, a plan at the Board of Health.
❑ ® Determined in the field (if any of the failure criteria related to Part C is at issue
approximation of distance is unacceptable) [310 CMR 15.302(5)]
D. System Information
Residential Flow Conditions:
Number of bedrooms (design): 3 Number of bedrooms (actual): 2
DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 330
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
�M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for y p W H annis ort Ma. 02672 5/13/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information
Description:
Number of current residents: 2
Does residence have a garbage grinder? ❑ Yes ® No
Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No
Laundry system, inspected? ® Yes ❑ No
Seasonal use? ❑ Yes ® No
Water meter readings, if available last 2 ears usage NA
9 ( y 9 (gpd))�
Detail:
Sump pump? ❑ Yes ® No
Last date of occupancy: 5/13/2010Date
Commercial/Industrial Flow Conditions:
Type of Establishment:
Design flow (based on 310 CMR 15.203); Gallons per day(gpd)
Basis of design flow(seats/persons/sq.ft., etc.):
Grease trap present? ❑ Yes ❑ No
Industrial waste holding tank present? ❑ Yes ❑ No
Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No
Water meter readings, if available:
t5ins•09108 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of W
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for y p W H annis ort Ma. 02672 5/13/2010
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Last date of occupancy/use: Date
Other(describe below):
General Information
Pumping Records:
Source of information:
Was system pumped as part of the inspection? ❑ Yes ® No
If yes, volume pumped: gallons
How was quantity pumped determined?
Reason for pumping:
Type of System:
® Septic tank, distribution box, soil absorption system
❑ Single cesspool
❑ Overflow cesspool
❑ Privy
❑ Shared system (yes or no) (if yes, attach previous inspection records, if any)
❑ Innovative/Alternative technology. Attach a copy of the current operation and
maintenance contract(to be obtained from system owner) and a copy of latest
inspection of the I/A system by system operator under contract
❑ Tight tank. Attach a copy of the DEP approval.
❑ Other(describe):
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17
Commonwealth of Massachusetts
Title 5 official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
°M 36 Maple Way
Y
Property Address
Robert Carr
Owner Owner's Name
information is required for W HY P annis ort Ma. 02672 5/13/2010
_
every page. CityFrown State Zip Code Date of Inspection
D. System Information (cont.)
Approximate age of all components, date installed (if known) and source of information:
2005
Were sewage odors detected when arriving at the site? ❑ ,Yes ® No
Building Sewer(locate on site plan):
Depth below grade: 26"feet
Material of construction:
❑ cast iron ® 40 PVC ❑ other(explain):
Distance from private water supply well or suction line: 10+
feet
Comments (on condition of joints, venting, evidence of leakage, etc.):
Joints appear tight.No evidence of leakage.system vented through the house vents.
Septic Tank (locate on site plan):
Depth below grade: 18"feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ® polyethylene ❑ other(explain)
If tank is metal, list age: years
Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No
Dimensions: 1500 gallon
Sludge depth:
4"
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for Y P W H annis ort Ma. 02672 5/13/2010
every page. Cityrrown State Zip Code Date of Inspection
D. System Information (cont.)
Septic Tank (cont.)
Distance from top of sludge to bottom of outlet tee or baffle
28"
Scum thickness 2"
Distance from top of scum to top of outlet tee or baffle
6"
Distance from bottom of scum to bottom of outlet tee or baffle
12"
How were dimensions determined? Measured
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Pump tank every two tears.lnlet and outlet tees are in place.No evidence of leakage.tank appears
structurally sound.
Grease Trap (locate on site plan):
Depth below grade: feet
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Scum thickness
Distance from top of scum to top of outlet tee or baffle
Distance from bottom of scum to bottom of outlet tee or baffle
Date of last pumping: Date
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for yannp
W H is ort Ma. 02672 5/13/2010
every page. CitylTown State Zip Code Date of Inspection
D. System Information (cont.)
Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity,
liquid levels as related to outlet invert, evidence of leakage, etc.):
Tight or Holding Tank (tank must be pumped at time of inspection) (locate on site plan):
Depth below grade:
Material of construction:
❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain):
Dimensions:
Capacity: gallons
Design Flow:
gallons per day
Alarm present: ❑ Yes ❑ No
Alarm level: Alarm in working order: ❑ Yes ❑ No
Date of last pumping: Date
Comments (condition of alarm and float switches, etc.):
*Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No
t5ins-09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
;M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for Y P W H annis ort Ma. 02672 5/13/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Distribution Box (if present must be opened) (locate on site plan):
Depth of liquid level above outlet invert No
Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any
evidence of leakage into or out of box, etc.):
Box is Ievel.Box has one outlet lateral.no evidence of solids carryover.No evidence of leakage.
Pump Chamber(locate on site plan):
Pumps in working order: ❑ Yes ❑ No
Alarms in working order: ❑ Yes ❑ No
Comments (note condition of pump chamber, condition of pumps and appurtenances, etc.):
Soil Absorption System (SAS) (locate on site plan, excavation not required):
If SAS not located, explain why:
I
l5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17
Commonwealth of Massachusetts
W Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for y p W H annis ort Ma. 02672 5/13/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Type:
❑ Teaching pits number:
® Teaching chambers number: 5-HC Infiltrators
❑ Teaching galleries number:
❑ leaching trenches number, length:
❑ leaching fields number, dimensions:
❑ overflow cesspool number:
❑ innovative/alternative system
Type/name of technology:
Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of
vegetation, etc.):
Sandy dry soil.no signs of hydraulic failure.Leaching was dry at time of inspection.
Cesspools (cesspool must be pumped as part of inspection) (locate on site plan):
Number and configuration
Depth—top of liquid to inlet invert
Depth of solids layer
Depth of scum layer
Dimensions of cesspool
Materials of construction
Indication of groundwater inflow ❑ Yes ❑ No
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17
i
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
° 36 Maple Way
M
Property Address
Robert Carr
Owner Owner's Name
information is required for y p W H annis ort Ma. 02672 5/13/2010
every page. City/Town State Zip Code Date of Inspection
D. System Information (cont.)
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
Privy (locate on site plan):
Materials of construction:
Dimensions
Depth of solids
Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation,
etc.):
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 14 of 17
Map Page 1 of 2
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Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for Y p W H annis ort Ma. 02672 5/13/2010
every page. Cityfrown State Zip Code Date of Inspection
D. System Information (cont.)
Site Exam:
® Check Slope
® Surface water
❑ Check cellar
❑ Shallow wells
Estimated depth to high ground water: Bottom of leaching 9'feet
Please indicate all methods used to determine the high ground water elevation:
® Obtained from system design plans on record
If checked, date of design plan reviewed: 2005
Date
❑ Observed site (abutting property/observation hole within 150 feet of SAS)
® Checked with local Board of Health -explain:
As-Built
❑ Checked with local excavators, installers- (attach documentation)
❑ Accessed USGS database-explain:
You must describe how you established the high groundwater elevation:
USED:USGS Observation Well Data.USED:Tachnical Bulletin 92-0001 plate#2 annual ranges of
groundwater elevations.
Before filing this Inspection Report, please see Report Completeness Checklist on next page.
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17
a
Commonwealth of Massachusetts
Title 5 Official Inspection Form
Subsurface Sewage Disposal System Form - Not for Voluntary Assessments
,M 36 Maple Way
Property Address
Robert Carr
Owner Owner's Name
information is required for y p W H annis ort Ma. 02672 5/13/2010
every page. CitylTown State Zip Code Date of Inspection
E. Report Completeness Checklist
® Inspection Summary: A, B, C, D, or E checked
® Inspection Summary D (System Failure Criteria Applicable to All Systems) completed
® System Information— Estimated depth to high groundwater
® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file
t5ins•09/08 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17
02/12/2016 20:48 FAX 16 001/002
'down of Barnstable
Regulatory Services
Thomas F. Ceiler,Director
-
� Public Health Division
Thomas McKean,Director
200 Main Street,Hyannis,MA 02601
Office: 508-8624644 Fax: 508-790-6304
Installer&Designer Certification Form
Date: 1 I/16/05
Resigner: Shay Environmental Services, Inc. Installer: Robert Septic Services.
Address: _P.O.Box 627 East Falmouth Address: 5 Trenton Street
MA 02536 Yarmouth, MA
On 9/27/05 Robert Septic Service was issued a permit to install a
(date) (installer)
septic system at 36 Maple Way, Hyannis, MA based on a design drawn by
(address)
Shay Environmental Services.Inc. dated�SWtember 26. 2005
(designer)
XX I certif"y that the septic system referenced above was installed substantially according to
the design, which may include minor approved changes such as lateral relocation of the
distribution box and/or septic tang,
I certify that the septic system referenced above was installed with major changes (i.e,
greater than 10' lateral relocation of the SAS or any vertical relocation of any component
of the septic system) but in accordance with State & Local Regulations. plan revision or
certified as-b ilt by d igner to follow,
*r�lti OF RASsE. �c
ller°s Signature) Y��` CARMEN '�,
SHAY us
No. 1181
esigner°s Signature) (Affix A ft p Here)
PLEASE RETURN TO BARNSTABLE PUBLIC HEALTH DIVISION. CERTIFICATE
OF COMPLIANCE WILL NOT BE ISSUED UNTIL BOTH THIS FORM AND AS-
BUILT CARD ARE RECEIVED BY THE BARNSTA13L PUBLIC HEALTH DIVISION.
THANK-'YOU.
Q;HeWtb/5eptivDesigner Certification Form
NOiSIA10
ho `6 WV 91 AoN SGOZ
3lQvjr3N8Vq jC, o
C11-
NO. Fee
THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
Yes
PUBLIC HEALTH DIVISION -TOWN OF BARNSTABLE., MASSACHUSETTS
ZIPPrication for Migozar *pgtem Construction Permit
Application for a Permit to Construct( )Repair)Upgrade( )Abandon( ) Acomplete System ❑Individual Components
Location Address or Lot No. a 6 M o PL.E WRY Owner's Name,Address and Tel.No.
Assessor's Map/Parcel � I 5A ME
Installer's Name,Address,and Tel.No. Designer's Name,Address and Tel.No.
Sepj�,C 8 VCS NAY E&A U. S\JzS
Type of Building:
Dwelling No.of Bedrooms��2- Lot Size �sq.ft. Garbage Grinder(Al/A
Other Type of Building ty Ot-)e No.of Persons Showers Cafeteria( t�
Other Fixtures t nylo_Nyr� e {tea -C San*_- , LA\34jpky
Design Flow gallons per day. Calculated daily flow s • gallons.
Plan Date Ct 17-112 w Number of sheets i Revision Date
Title
Size of Septic Tank Type of S.A.S. V
Description of Soil; CIA— Nt. e_n
l®`X3�' �cl°
Nature of Repairs or Alterations(Answer when applicable) '4_-1QaC— -)v-_ DN0.0.
Date last inspected:
Agreement:
The undersigned agrees ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisi ns of Title 5 of the Environmental Code and not to place the system in operation u til a ertifi-
cate of Compliance has been is ed b his Board. alth.
Sign Date
Application Approved by Date
Application Disapproved for the following reaso
Permit No. Date Issued
-No. .
T ; THE COMMONWEALTH OF MASSACHUSETTS Entered in computer:
;Y.
r PUBLIC HEALTH DIVISION - TOWN OF BARNSTABLES MASSACHUSETTS
Application f or Bi!gp0$,ht *pgtem Cougtruction Permit
Application for a Permit to Construct( )Repair)Upgrade( )Abandon( ) Complete System ❑Individual Components
`Location Address or Lot No. 3(o M A PL_E WAY Owner's Name,Address and Tel.No,
Assessor'sMap/Parcel ��r�JrJ�S
Installerls Name,Address,and Tel.No. ! Designer's Name,Address and Tel.No1
Sep-.0 !J�1CS . '5'AOY EN U. SA�'0
s39- -4R�De
Type of Building:
Dwelling,' No.of Bedrooms Lot Size sq.tft. l ' Garbage Grinder(��R
Other Type of Building KN r\r-�p No.of Persons } Showers(/ ) Cafeteria( V6
�-� ,v,a� �`--r—
'Other Fixtures I � Y
Design Flow gallons per day. Calculated daily flow N .Eto gallons.
' Plan Date .[o S Number of sheets Revision Date
Title `7 acd A Snr*A-;r
p \ K k Type off S.A. S. ��. 'rnj fA,rrS .
.; Size of Se tic Tank kA* .� l n �,
Description of Soil AMC- t pX'3-+ X 1'
� T
Nature,of Repairs or Alterations(Answer when applicable) o �-
Date last inspected:
Agreement: .
The undersigned agrees to ensure the construction and maintenance of the afore described on-site sewage disposal system
in accordance with the provisions of Title 5 of the Environmental Code and not to place the system in operation until a Certifi-
cate of Compliance has been isted by his BoardvooPHealth.
Signe �. t 1 Date C iJ
Application Approved by' Date
'Application Disapproved for the following reason
Permit No. Date Issued ni
p�
THE COMMONWEALTH OF MASSACHUSETTS
BARNSTABLE, MASSACHUSETTS
Certificate of (Compliance
THIS IS TO CERTIF ,)that the On-site Sewage Disposal System Constructed( )Repaired( )Upgraded(V)
Abandoned )by 7 r
at l h s be constructed in accordance
with the provisi s of Title Sand the-for Disp ystem Cons ction Permit No dated c�7 �.
Installer Designed
The issuance of this1permit hall�not�be construed as a guarantee thati�the syste i f 5,11n as de d
Date f s �'� Inspectar
— ---- --—
r Fee
THE COMMONWEALTH OF MASSACHUSETTS
PUBLIC HEALTH DIVISION - BARNSTABLES MASSACHUSETTS
Digonl *p.5tem Con!9truction Permit
Permission is hereby granted to Constr ct( )+ epair( )Upgrade(�)Abandon( )
System located at. ✓ /
and as described igh_e above pplication for Disposal System Construction Permit. The applicant recognizes his/her duty to
comply with Title 5 and the following local provisions or special conditions.
Provided: Constructio must a completed within three years of the date of thiscrin
Date:__� Approved by
9/16/03
Notice: This Form Is To Be Used For the Repair Of Failed
Septic Systems. Only
PERCOLATION TEST AND SOIL EVALUATION EXEMPTION FORM
I, S444 ,hereby certify that the engineered plan signed by me
dated 62(o concerning the property located at
to IA Q:: tau t-,i5 meets all of the.
following criteria:
0 This failed system is connected to a residential dwelling only. There.are.no.commercial or
business uses associated with the.dwelling.
0 The soil is classified as.CLASS I and the percolation rate is less than or equal to 5 minutes
per inch. The applicant may use historical data to conclude this fact or.may conduct deep
test holes and percolation tests.at the site without a health agent present.
• There is no.increase in flow and/or change in use proposed
• There are no variances requested or needed.
• The.bottom of the proposed leaching facility will be located no less than five feet above the
maximum adjusted groundwater table elevation. [Adjust the groundwater table using the.
Frimptor method when applicable]
Please complete the following:
A) Top of Ground Surface Elevation(using GIS information). , b Q
B) G.W.Elevation (R +adjustment for high G.W. c� �= 4
DIFFERENCE BETWEEN A and B ( ,
qQQSIGNED : DATE:
NOTICE
Based upon the above information; a repair permit vwill be issued for bedrooms
maximum.. No additional bedrooms are authorized in the future without engineered septic system
plans.
gASeptic\percexemp.doc
*NOTE: ALL PIPES ARE TO BF 4" SCHEDULE 40 P.V.C.
i 10' min. from VENT PIPE (o Least 24 inches tan ilter SECTION A „u OUTLET DES FROM n,E M ^
Existing Foundation house to septic tank Schedule 40 PVC w/Chorcool Odor F myRmnom 9ox SMALL IRE
TOP OF FOUNDATION = ELEV. 100.00 (Assumed) Septic tank covers must be -o-Box cover must be PROFILE VIEW OF ADDITION TO LEACHING SYSTEM SET LEVEL FOR AT LEAST 2 fT 12• CONCRETE COVER
rifhul 6 in. of finished grade rithin 6 in. d finished grade
-- - �-Grade over Septic Tank - 99.00 �Groda over D-Box - 99.50 XZ I I over SAS - 99.50 3" of 1/8" - 1/2" Washed Peostorx I 3 - 5"OUTLET _ 2 _
3/4' to 1 1/2 Washed Crushed Stone XNOCxouTs s - Rd
>? h
7 J 5.5• _ I 12• INLET tN _
S 0.02 3 HOLE H-10 4' PVC (CAPPED) NSPEC110N PORT TO BE OUTLET I
1ST. BOX 3' Maximum Corer T OF S .m- Elev. -96.1♦ INSTALLED AND TO BE 1MTFMl S' OF GRADE - Y f3• i - Hy•w
Top r•t cu
0 1r - s�o.o1 a cr.atHK - -
ExtsT. P'" �L=F
FROM EXIST. FUUNDATIOM N30' s- 0.01• per ",at 10'" Erlecti.. --15.5•- 4" - SCH. 40 T"
rn ca Depth 175•
co
a 5 s units a 6.25 = 3o PLAN SECTION CROSS-SECTION
CONCRETE FtAL o v Ch J0.83' (10 inches) v
'iiO I y
SYSTEM PROFILE a ti.w 3/`"-"� m ' 3 31.25' 3 3 HOLE H-10 DISTRIBUTION BOX _
compacted stone o NOT TO SCAM
Not to Scale - c JA �- 37.25' ®5m> 3.5,- I --3.5' p Effective Length Oda;Ww le it&,s:wsr.®:BOs
3 ' u SOIL ABSORPTION SYSTEM (SAS)
_ s inaf 3/.•-„/2- 0 10 GENERAL NOTES
compacted stone Q Effective Vidth
o INFILTATR❑ M R HIGH CAPACITY -20 LOADING)/ GE❑RGE ❑'BRIEN
NOTE: ALL COMPONENTS MUST HAVE RISERS TO WITHIN 6" BELOW GRADE o 1 Contractor is responsible for Digsafe notification, Verification of Utilities
o (OR EQUIVALENT) Not to Scale and protection of all underground utilities and pipes.
Bottom of Test Hde 1 E1eONE OBSERVED
NOTE: OVERALL HEIGHT OF INFILTRATOR IS 18� FFECTIVE HEIGHT IS 10" P
w 2. The septic tank and distribution box shall be set
Groundrater Observed - NONE OBSERVED___ level on 6" of 3/4"-1 1/2" stone.
-- --- -----
-- 3. Backfill should be clean sand or gravel with no
- stones over In size.
4. This system is subject to inspection during installation
PERCOLATION TEST ��� by Carmen E. Shay - Environmental Services, Inc.
5. The contractor shall install this system in accordance
Date of Percolation Test: SEPTEEMBER 23, 2005 - with Title V of the Massachusetts state code, the approved plan
Test Performed By. CARMEN E. SHAY, R.S., C.S.E. I and Local Regulations.
Results Witnessed By. WAIVER (Per Barnstable B.O.H.) i 6 If, during installation the contractor encounters any
EXCAVATOR: Shay Env. Svcs. I soil conditions or site conditions that are different
Percolation Rate: Less Than 2 MPI 036' i from those shown on the soil log or in our design
-- -- -- I installation must halt & immediate notification be
Test Hole j i Test Hole i made to Carmen E. Shay - Environmental Services, Inc.
NO. 1 NO. 2 1 7 No vehicle or heavy machinery shall drive over the
DEPTH SOILS ELEVA DEPTH SOILS ELEV. I septic system unless noted as H-20 septic components.
0 _ 99.0_0i 0 98.50 1 8. Install Tuf-Tite gas baffles or equals on all outlet tee ends.
Sandy Loam Sandy Loam 9. All Distribution Lines shall be 4" diameter Schedule 40 NSF PVC pipes.
1D YR 3/2 ,o YR 3/2 Q i 10. All solid piping, tees & fittings shall be 4" diameter
0'-9" A. 98.25 I - --- Schedule 40 NSF PVC pipes with water tight joints.
0'-6" As 98.00 I NOTE_: HOUSE IS ON A CONCRETE SLAB FOUNDATION
y
Sand L I 11. Municipal Water is Connected to ALL of The Residence and Abutting
Loam j Loamy O SAS ONLY REQUIRED TO BE 10 FEET FROM FOUNDATION Properties Within 150 Feet.
10 YR 5/6 I 10 YR 5/6F
9"_ 36" Be 96�, z I THE PROPERTY LINES ARE APPROXIMATE AND
6"- 36" Be, 95.50 O
Medium/Coarse `1 COMPILED FROM THE SURVEY PLAN GENERATED BY
Medium/Coarse V
1 FRED 0. SMITH, C.E. OF YARMOUTH, MA
end Sand l- ENTITLED "PLAN OF SEASIDE PARK, HYANNIS, MA",
2.5 Y 7/4 15 Y 7/4 O 1 DATED AUGUST, 1893 , PLAN BOOK 34 PAGE 23
36"- 132 G L` I AND IS NOT INTENDED TO BE A SURVEY PLOT PLAN
3s'- t3z I IT SHOULD BE USED FOR NO PURPOSE OTHER THAN
1
� 1 THE SEPTIC SYSTEM INSTALLATION.
- I rn EXISTING CESSPOOLS TO BE PUMPED OUT REMOVED.
I
l 80.00 1
NOTE: ANY STRIPPED OUT SOIL CONTAINING LEACHATE
I \ --- - � ------------� Failed - - -- ----
FROM THE EXISTING CESSPOOLS TO BE DISPOSED
l OF AS PER BOARD OF HEALTH SPECIFICATIONS.
Cesspool-�-� � ,.
- - ---- - -- -- - - - 1 EXIST. -
DRIVEWAY 1
I THERE ARE NO WETLANDS ARE PRESENT WITHIN 200' OF THE PROPERTY
Perc #1 , � NEW 1500 GAL.
Depth to Perc 40" to 58' l SEPTIC TANK
Perc Rate= 2 MPI F ASSESSORS MAP 246 PARCEL 132 - - _
L lduczaCl -WoteFV-Line- - SCREEN - -- - -
-
Groundwater Not Observed i LEGEND
No Observed ESHWT l PORCH O _
ADJUSTED H2O Elev. = None i l
3-24• DIAM ACCESS MANHOLES I O I O
- O EXISTING -- PROJECT BENCH MARK [104X1 DENOTES PROPOSED
SPOT GRADE
10' -c --- - ' 3 BEDROOM TOP OF FOUNDATION
- = ' HOUSE ELEV. = 100.00 (Assumed) DENOTES EXISTING
�t3s x 104.46 SPOT GRADE
l 1 n \\\ (ON SLAB FOUNDATION)
PL PROPERTY IINE
NlE 1 1 1 \
INLET �... \ OU T \
THE ACCESS COVERS FOR THE SEPTIC TANK, 96P - PROPOSED CON I OUP
k LOTS' #406 & 408 -
DISTRIBUTION BOX AND LEACHING COMPONENT -
- SHALL BE RAISED TO WITHIN 6' Of .000 Sq vase Feet +�-
T' FINISHED GRADE. , I - - -97 EXISTING CONTOUR
STEEL REINFORCED PRECAST CONCRETE INSTALL TUF-TITS GAS BAFFLES OR EQUALS I l
ON ALL OUTLET TEE ENDS
PLAN VIEW TEST HOLE y1 DEEP TEST HOLE &
3-24• REMOVABLE COVERS 1 I ELFV.= 99.00
j I , PERCOLATION Tc ` , A 1i
- i 11
3 min clearance - t' A
NLET e" min.T 12" mk+. kvlet to outlet s. I h3, e4FT'f i \\ f , +!
-�-- �__ • • •
7- - OUTLET I jrQ t •t• /
INLE ta'Imk+. ' r LIquW level I -,` ` / ------ - -- --- -- -- ------ - ---
5 -r J I " +I "'- .� ti �1 D BOX /
E Q ' 1 _- __y - i
4 uld min. 1 TEST HOLE 2 Q ' 37.25' )p`=- LO
T. "Qe" �p� ELEV.= 98.50
.s I 1 80.00
P LAN
__ PL
OF PROPOSED SEPTIC SYSTEM UPGRADE_
CROSS SECTION END-SECTION PREPARED FOR
---TYPICAL (H- 10 LOADING) 1500 GALLON SEPTIC TANK M R . PAU E OTTOAT
NOT TO SCALE FIFTH VEIv UE # J6 MAPLE WAY
May Substitute with 1500 gallon H-10 Polyethylene Tank-George O'Brien Co. HYAN N I S , MA
-- (40 FOOT RIGHT OF WAY)
Design Calculations - -
\� ssq PREPARED BY:
Number of Bedrooms: 2 Equivalent to 220 Gal./Day (330 Gal./Day Min. per Title V)Garbage Grinder: No Leaching
�= ARAITN 17. Sff/� l
v
Leaching Capacity Proposed: 330 Gal./Day Minimum (Min. Per Title V) � E.
Septic Tank - 2 x 330 Gal./Day = 660 USE NEW 1.500 GAL. POLYETHYLENE Septic Tank. Y `� NVIRONMENTAL SERVICES, INC.
SOIL ABSORPTION AREA: Using percolation rate of <2 min./inch
Bottom Area: 0.74 gal/sq. ft. x 372.5 sq. ft. = 275.65 gallons P.O. BOX 627
Sidewall Area: 0.74 gol./sq. ft. x 78.72 sq. ft. = 58.25 gallons 0 20 40 50 EAST FALMOUTH, MA 02536
Providing: = 333.90 gallons Sq .ITAR TEL/FAX : 508-539-7966
Use: (5) INFILTRATOR HIGH CAPACITY H-20 UNITS, HAVING A 0.83' (10 INCHES) EFFECTIVE DEPTH,
SCALE: 1 "=20' DRAWN BY: CES DATE: SEPT. 26, 2005
TO BE USED WITH 3.5' OF WASHED STONE ON THE SIDES, AND 3.5' OF WASHED STONE
ON THE ENDS. NO STONE UNDER. SCALE: 1 "=20' PROJECT#SD807 FILENAME: SD807PP.DWG SHEET 1 OF 1